Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director,...
-
Upload
belinda-bond -
Category
Documents
-
view
218 -
download
1
Transcript of Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director,...
![Page 1: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/1.jpg)
Burning Issues with UTIs
Meghan Brett, MDDivision of ID
Hospital EpidemiologistMedical Director, Antimicrobial Stewardship
![Page 2: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/2.jpg)
Objectives• Distinguish between asymptomatic bacteriuria (ASB) and different
types of active UTIs (complicated vs. uncomplicated)
• Describe in which patients ASB should be treated
• Learn how to diagnose a catheter-associated UTIs (CAUTIs)
• Describe how to determine empiric treatment and how long uncomplicated UTIs should be treated
• Know how to access and use various antibiograms and other resources
![Page 3: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/3.jpg)
What’s the Burden of UTIs?
• 50% of women will have a UTI in their lifetime– Up to 25% may have a second UTI within 6 months
• Visits related to UTI– 3 million ED visits in 2010– Most common primary diagnosis for U.S. women visiting EDs– 100,000 hospitalizations in U.S.– 0.9% of all ambulatory visits
• Half of all UTIs were among patients age 18 to 44 years• Pts visiting the ED have higher acuity than those pts
presenting to primary care– 400,000 (13%) were for pyelo (13 visits/10,000 people)– In general population: 1 case/28 cases of cystitis
![Page 4: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/4.jpg)
Who is Most Affected by UTIs?
• Annual Incidence of UTIs– Young, sexually active women: 2 – 4%– Women > 70 yrs: 5 – 10%– Women > 80 yrs: 50%– Institutionalized Women: 40%– Adult men (childhood through middle age): < 1%– Men > 65 yrs: 1 – 3%– Men > 80 yrs: 10%– Institutionalized Men: 25%
• CAUTIs: ~1 million/year
![Page 5: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/5.jpg)
What Are Take Home Points?
• Assemble the whole clinical picture (i.e., limiting reflexive Rx of positive Urine Cx)
• Determine the syndrome• Distinguish between complicated vs.
uncomplicated UTIs• Choose appropriate empiric antibiotics based on
likely bacterial etiologies and their resistance• Adjust antibiotics based on culture results• Decide about length of therapy
![Page 6: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/6.jpg)
Questions (1st Set)• How do you define asymptomatic bacteriuria ASB?
• How do you differentiate between asymptomatic bacteriuria and UTI?
• Which groups need to be treated for ASB?
• What criteria do you use to define uncomplicated vs. complicated UTIs?
• Why does distinguishing uncomplicated vs. complicated help?
• What kinds of questions would you ask to distinguish between uncomplicated and complicated?
![Page 7: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/7.jpg)
Asymptomatic Bacteriuria
• Asx women: 2 consecutive voided urine specimens with isolation of same bacterial strain in quantitative counts ≥ 105 cfu/mL
• Men: single, clean-catch voided specimen with 1 bacterial species isolated in quantitative counts ≥ 105 cfu/mL
• Women or men: single catheterized specimen with 1 bacterial species isolated in quantitative count ≥ 102 cfu/mL
Infectious Diseases Society of America (IDSA), ASB guidelines 2005
![Page 8: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/8.jpg)
![Page 9: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/9.jpg)
ASB
• Evidence that screening and treatment does not lead to improved clinical outcomes
• More likely, unnecessary antibiotics may cause harm– Adverse effects– C difficile infection– Antibiotic resistance– Wasted expense
![Page 10: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/10.jpg)
UTI Signs/Sx
![Page 11: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/11.jpg)
Clinical Presentation – Distinguishing ASB vx. UTI
• Lower tract signs– Dysuria– Frequent urination– Urgent urination
• DDX:– STIs– Vaginitis– Exposure to chemical or allergic irritants
![Page 12: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/12.jpg)
Clinical Presentation – Distinguishing ASB vx. UTI
• Upper tract:– Fevers, chills– Nausea– Flank pain– Often also with dysuria/frequency/urgency
![Page 13: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/13.jpg)
Which Groups Require Rx for ASB?
• Definitive:– Pregnant Women– Anyone undergoing TURP or Urologic procedures
during which mucosal bleeding is anticipated• Maybe:– Renal transplant patients– Neutropenic patients
Infectious Diseases Society of America (IDSA), ASB guidelines 2005
![Page 14: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/14.jpg)
Uncomplicated vs. Complicated
• Uncomplicated – premenopausal women– No structural or functional abnormalities in urinary
tract– Not pregnant
• Complicated – – Structural abnormalities (e.g., nephrolithiasis)– Functional abnormalities (e.g., ureteral reflux)– Compromised hosts (e.g., pregnant, diabetic)– UTIs in boys/men: until structural/functional ruled
outIDSA, Uncomplicated UTI Guidelines 2011Dielubanza EJ. ID Clin N Am 2014.
![Page 15: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/15.jpg)
Why Distinguish Between Uncomplicated vs. Complicated?
• Guidelines for uncomplicated but none for complicated UTIs
• More important than upper tract/lower tract• Complicated – May need further evaluation (diagnostics, urology consult)– Increased morbidity and mortality– May encounter more drug resistance (IV ABX)– Duration of therapy will likely be longer
• Assess conversion from uncomplicated to complicated (may indicated underlying issues)
![Page 16: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/16.jpg)
Questions to Distinguish Uncomplicated from Complicated
• Pregnancy status• History of kidney stones• Structural/functional GU abnormalities• Pelvic surgery• DM• Neurologic disorders• Recent ABX use• Recent hospitalization• Recent GU instrumentation
![Page 17: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/17.jpg)
Questions (2nd Set)
• What’s the best way to obtain a urine sample for diagnosing a UTI?
• What are indications for having a Foley catheter?
• What tests do you review on a urinalysis to make you consider a UTI? ASB?
• How do you diagnose a CAUTI?
![Page 18: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/18.jpg)
Key Issue – Urine Sample Collection
• Clean-catch, mid-stream = best• In/Out catheterization• DO NOT insert Foley catheters for sake of
urine collection (unless otherwise indicated)
![Page 19: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/19.jpg)
Indications for Foley Catheters
• Patients with hemodynamic instability (e.g., on pressors) who require urine output monitoring
• Urinary obstruction/retention • Sacral or perineal wounds in patients with
incontinence • Genitourinary surgery/Placed by a Urologist • Requires prolonged immobilization (unstable
spine) • End of life care
CDC (HICPAC) CAUTI Prevention Guidelines, 2009http://www.cdc.gov/HAI/ca_uti/uti.html
![Page 20: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/20.jpg)
Review of UA for Evidence of Infection
• Check squamous cells first… if > 20, likely a contaminated sample
• Nitrites– Produced by many Gram-negatives– Requires hours for conversion of nitrate nitrite– Not by Gram-positives, candida species
• WBCs– > 10 per high powered field
• Leukocyte esterase– Enzyme found in neutrophils– If present, indicates neutrophil activity
![Page 21: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/21.jpg)
Caveats
• Pyuria in ASB does not need to be treated• Urine samples that sit will have alterations in
UA results– Samples analyzed within 2 hours or refrigerated to
limit false positive and false negative results
![Page 22: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/22.jpg)
![Page 23: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/23.jpg)
![Page 24: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/24.jpg)
![Page 25: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/25.jpg)
Questions (3rd Set)• How do you select an antibiotic for empiric treatment
treatment?
• When do you change from empiric to directed antibiotic therapy?
• How long do you treat uncomplicated cystitis? Uncomplicated pyelonephritis?
• How do you treat CAUTIs? For how long?
• Do you test urine for cure? Why?
![Page 26: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/26.jpg)
Treatment of UTIs – What Bugs?
• Enteric flora colonizing perineum and urethra• E. coli
– 80% of first infection in women, men, children– 50% of nosocomial UTIs– Most common for acute uncomplicated cystitis– Many episodes of complicated UTIs and pyelo
• Staphylococcus saprophyticus– 11% of UTIs (sexually active, younger women)
• Remaining– GNRs (Klebiella, Proteus mirabilis) increasingly MDROs– Gram-positive cocci (entercoccus and GBS)
![Page 27: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/27.jpg)
What’s First Line Therapy (Empiric Treatment)? – Uncomplicated Only!
• Antimicrobial Stewardship Clinical Pathway (with a focus on inpatients)
![Page 28: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/28.jpg)
Change from Empiric to Directed?
• When you have culture results• Look at susceptibility interpretations• Determine what has good urine/kidney
penetration• Lowest MIC ≠ Best ABX selection• Questions? Call Antimicrobial Stewardship!
(on amion.com)
![Page 29: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/29.jpg)
How Long to Treat?
• It depends!• Uncomplicated UTIs– Cystitis
• Nitrofurantoin or Bactrim 3 days• 20% resistance in isolates is an indication not to use this for
empiric coverage• Note: nitrofurantoin should not be used in patients with
Creatinine clearance < 50 (does not reach bladder)– Pyelonephritis
• FQ 5 – 7 days• Beta-lactams 10 – 14 days• Bactrim 14 days
![Page 30: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/30.jpg)
How Long to Treat CAUTIs?
• 7 days of treatment for patients with CAUTI who have prompt resolution of symptoms
• 10 – 14 days in patients with delayed response to treatment
• 3 day regimen may be considered for women ≤ 65 yrs who develop CAUTI without upper tract sx after a catheter has been removed
![Page 31: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/31.jpg)
Test of Cure?
• Nope (please don’t)
![Page 32: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/32.jpg)
Other Notes
• Complicated including CAUTIs– Polymicrobial for longer-term (>30d) indwelling
catheters– More drug resistant (ESBLs, P. aeruginosa, or
enterococcus faecium)• S. aureus – what to do?
![Page 33: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/33.jpg)
Treatment of CAUTIs
• Algorithm to be developed
![Page 34: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/34.jpg)
Greatest Overuse of Antibiotics
It’s ASBpatient’s positive urine cx
![Page 35: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/35.jpg)
Unintended Consequences of ABX
• Drug reactions• C difficile infections• Selection for drug resistance
• Stay tuned… impact to the microbiome
![Page 36: Burning Issues with UTIs Meghan Brett, MD Division of ID Hospital Epidemiologist Medical Director, Antimicrobial Stewardship.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649d925503460f94a78504/html5/thumbnails/36.jpg)
Resources
• https://hospitals.health.unm.edu/intranet/Index.cfm
• https://hospitals.health.unm.edu/intranet/antimicrobial/pathways.shtml
• http://www.tricore.org/Healthcare-Professionals/Test-Information/Antibiograms
ASP – Inpt Antibiograms and Clinical Pathways
Tricore – Outpatient Antibiograms